Creating affiliations, learning, and mindfulness for in vitro fertilization patients (CALM IVF): a clinical trial.

Objective: Determine if group psychoeducational support can improve in vitro fertilization (IVF) patients' quality of life (QoL). Design: Randomized controlled trial (NCT04048772). Setting: University-affiliated IVF clinic. Patients: Women (n = 76) and male partners undergoing initial autologous IVF cycle from August 2019, to December 2020. Interventions: Couples were assigned to groups based on projected oocyte retrieval date. Groups were randomly assigned to the control or intervention arm. Clinic closures because of the COVID-19 pandemic delayed treatment for a portion of participants. Groups were conducted in person before and virtually during the pandemic. Main Outcome Measures: The primary outcome was a change in fertility quality of life (FertiQoL) from baseline to 3 days after retrieval. Secondary outcomes were changes in depression (Patient Health Questionnaire 9), anxiety (Generalized Anxiety Disorder 7), resilience (Connor-Davidson Resilience scale), IVF knowledge scores, and the likelihood of return to treatment. Results: Knowledge scores among women in Creating Affiliations, Learning, and Mindfulness (CALM) for IVF groups significantly increased compared with control (mean difference 13.19 [3.53 - 22.84]) before the pandemic. During the pandemic, women in CALM IVF had significant improvement in the social FertiQoL score compared with controls (10.42 [1.79 - 19.04]). Compared with controls, male CALM IVF participants had significantly greater improvement in total FertiQoL (mean difference 6.68 [0.39 - 12.98]), treatment FertiQoL (8.26 [0.69 - 15.82]), and resilience (Connor-Davidson 1.13 [0.54 - 1.72]). Immediate return to care did not significantly differ between arms. Conclusions: For women undergoing IVF, group psychoeducational programs can improve IVF knowledge and social QoL during a pandemic. Participation in a group psychoeducational program can improve QoL and resilience in IVF dyad male partners. Clinical Trial Registration Number: Trial registration NCT04048772.

Public opinions regarding infertility treatment insurance coverage among marginalized patient populations.

PURPOSE: To assess public support for insurance coverage of infertility treatment among marginalized patient groups. METHODS: A cross-sectional, web survey-based study using a national sample of 1226 US adults. Participants responded to questions measuring their beliefs and attitudes towards support for infertility treatment insurance coverage among specific patient populations. We then evaluated the opinions of only the participants who supported infertility treatment insurance coverage for patients meeting the standard definition of infertility. Associations between demographic data of participants and support for infertility treatment insurance coverage among these marginalized groups were queried. RESULTS: Of the total responses, 61.9% of the respondents generally supported insurance coverage for infertility. Of the total responses, 54.5% did not support any insurance coverage for lesbian, gay, or transgender patients. Of those who generally supported the insurance coverage for infertility, 53.0% supported coverage for gay patients requiring infertility services, 54.6% supported coverage for lesbian patients, and 42.5% supported coverage for transgender patients. Of the total responses, 47.6% did not support insurance for green card holders, undocumented immigrants, or refugees. Of those who supported the insurance coverage for infertility in general, 63.6% supported insurance coverage for patients with green cards, 29.8% for refugees, and 20.7% for undocumented patients. For disability and genetic conditions, 39.5% did not support coverage for any groups. Of those who support the insurance coverage for infertility in general, there was most support for patients with physical disabilities (60.2%) followed by genetic disease (47.9%), then mental disabilities (31.4%). CONCLUSION: Even among those who support insurance coverage for infertility in general, approximately less than half of them supported these same treatments for marginalized groups, including the diverse sexuality and gender (DSG), immigrant, and disabled populations. Increased education and awareness of infertility is needed among the general population to garner acceptance of infertility as a disease and support insurance coverage of infertility treatment for all persons.

Cumulative live birth rate in women aged ≤37 years after in vitro fertilization with or without preimplantation genetic testing for aneuploidy: a Society for Assisted Reproductive Technology Clinic Outcome Reporting System retrospective analysis.

Objective: To investigate cumulative live birth rates (CLBRs) in cycles with and without preimplantation genetic testing for aneuploidy (PGT-A) among patients aged <35 and 35-37 years. Design: Retrospective cohort study. Setting: Society for Assisted Reproductive Technology reporting clinics. Patients: A total of 31,900 patients aged ≤ 37 years with initial oocyte retrievals between January 2014 and December 2015 followed through December 2016. Interventions: None. Main outcome measures: The primary outcome was CLBR among patients aged <35 and 35-37 years. The secondary outcomes included multifetal births, miscarriage, preterm birth, perinatal mortality, and the time to pregnancy resulting in a live birth. Adjusted odds ratios (aORs) adjusting for age, body mass index, total 2 pronuclei embryos, embryos transferred, and follow-up timeframe. Results: Among patients aged <35 years, PGT-A was associated with reduced CLBRs (70.6% vs. 71.1%; aOR, 0.82; 95% CI [confidence interval], 0.72-0.93). No association was found between PGT-A and CLBRs among patients aged 35-37 years (66.6% vs. 62.5%; aOR, 0.92; 95% CI, 0.83-1.01). Overall, there was no significant difference in the miscarriage rate (aOR, 0.97; 95% CI, 0.82-1.14). Multifetal birth rates were lower with PGT-A (9.5% vs. 23.1%); however, PGT-A was not an independent predictor of multifetal birth (aOR, 1.11; 95% CI, 0.91-1.36). The average time to pregnancy resulting in a live birth was 2.37 months (SD 3.20) for untested transfers vs. 4.58 months (SD 3.53) for PGT-A transfers. Conclusions: In women aged <35, the CLBR was lower with PGT-A than with the transfer of untested embryos. In women aged 35-37 years, PGT-A did not improve CLBRs.

The Effect of Financial Incentives on Adherence to Glucose Self-Monitoring during Pregnancy among Patients with Insulin-Requiring Diabetes: A Randomized Clinical Trial.

OBJECTIVE: Glucose self-monitoring is critical for the management of diabetes in pregnancy, and increased adherence to testing is associated with improved obstetrical outcomes. Incentives have been shown to improve adherence to diabetes self-management. We hypothesized that use of financial incentives in pregnancies complicated by diabetes would improve adherence to glucose self-monitoring. STUDY DESIGN: We conducted a single center, randomized clinical trial from May 2016 to July 2019. In total, 130 pregnant patients, <29 weeks with insulin requiring diabetes, were recruited. Participants were randomized in a 1:1:1 ratio to one of three payment groups: control, positive incentive, and loss aversion. The control group received $25 upon enrollment. The positive incentive group received 10 cents/test, and the loss aversion group received $100 for >95% adherence and "lost" payment for decreasing adherence. The primary outcome was percent adherence to recommended glucose self-monitoring where adherence was reliably quantified using a cellular-enabled glucometer. Adherence, calculated as the number of tests per day divided by the number of recommended tests per day×100%, was averaged from time of enrollment until admission for delivery. RESULTS: We enrolled 130 participants and the 117 participants included in the final analysis had similar baseline characteristics across the three groups. Average adherence rates in the loss aversion, control and positive incentive groups were 69% (SE=5.12), 57% (SE = 4.60), and 58% (SE=3.75), respectively (p=0.099). The loss aversion group received an average of $50 compared with $38 (positive incentive) and $25 (control). CONCLUSION: In this randomized clinical trial, loss aversion incentives tended toward higher adherence to glucose self-monitoring among patients whose pregnancies were complicated by diabetes, though did not reach statistical significance. Further studies are needed to determine whether use of incentives improve maternal and neonatal outcomes. KEY POINTS: · Self-glucose monitoring is a critical part of diabetes management in pregnancy.. · Loss aversion financial incentives may increase adherence to glucose self-monitoring in pregnancy.. · The impact of testing incentives on maternal and neonatal outcomes requires further investigation..

Intracytoplasmic sperm injection vs. conventional in vitro fertilization in patients with non-male factor infertility.

OBJECTIVE: To compare the cumulative live birth rates (CLBRs) and cost effectiveness of intracytoplasmic sperm injection (ICSI) and conventional in vitro fertilization (cIVF) for non-male factor infertility. DESIGN: A retrospective cohort study. SETTING: Society for Assisted Reproductive Technology clinics. PATIENT(S): A total of 46,967 patients with non-male factor infertility with the first autologous oocyte retrieval cycle between January 2014 and December 2015. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The primary outcomes were CLBR, defined as up to 1 live birth from an autologous retrieval cycle between 2014 and 2015, and linked fresh and frozen embryo transfers through 2016. The secondary outcomes included miscarriage rate, 2 pronuclei per oocyte retrieved, and the total number of transferred and frozen embryos. Analyses were performed on subsamples with and without preimplantation genetic testing for aneuploidy (PGT-A). A cost analysis was performed to determine the costs accrued by ICSI. RESULT(S): Among cycles without PGT-A in patients with non-male factor infertility, the CLBR was 60.9% for ICSI cycles vs. 64.3% for cIVF cycles, a difference that was not significantly different after adjustment for covariates (adjusted risk ratio, 0.99; 95% confidence interval, 0.99-1.00). With PGT-A, no difference in CLBR was found between ICSI and cIVF cases after adjustment (64.7% vs. 69.0%, respectively; adjusted risk ratio, 0.97; 95% confidence interval, 0.93-1.01). The patients were charged an estimated additional amount of $37,476,000 for ICSI without genetic testing and an additional amount of $7,213,500 for ICSI with PGT-A over 2 years by Society for Assisted Reproductive Technology clinics. CONCLUSION(S): In patients with non-male factor infertility, ICSI did not improve CLBR. Given the additional cost and the lack of CLBR benefit, our data show that the routine use of ICSI in patients with non-male factor infertility is not warranted.

Fresh embryo transfer after in vitro insemination of fresh vs. cryopreserved anonymous donor oocytes: which has a better live birth rate? A Society for Assisted Reproductive Technology Clinic Outcome Reporting System analysis.

OBJECTIVE: To determine if transfer of fresh embryos derived from fresh or cryopreserved donor oocytes yields a higher live birth rate. DESIGN: Historical cohort study. SETTING: Society for Assisted Reproductive Technology Clinic Outcome Reporting System database. PATIENT(S): A total of 24,663 fresh embryo transfer cycles of donor oocytes. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The primary outcome was live births per number of embryos transferred on day 5. The secondary outcomes included number of infants per embryo transfer, surplus embryos cryopreserved, and characterization of US oocyte recipients. RESULT(S): A total of 16,073 embryo transfers were from fresh oocytes and 8,590 were from cryopreserved oocytes. Recipient age, body mass index (BMI), gravidity, and parity were similar between the groups. Most recipients were of White non-Hispanic race (66.9%), followed by Asian (13.7%), Black non-Hispanic (9.3%), and Hispanic (7.2%). Fresh oocyte cycles were more likely to use elective single embryo transfer (42.5% vs. 37.8%) or double embryo transfer (53.2% vs. 50.4%) and resulted in more surplus embryos for cryopreservation (4.6 vs. 1.2). The live birth rate from fresh oocytes was 57.5% vs. 49.7% from cryopreserved oocytes. Negative predictors of live birth included the use of cryopreserved oocytes (odds ratio [OR] 0.731, 95% confidence interval [CI] 0.665-0.804), Black non-Hispanic race (OR 0.603, 95% CI 0.517-0.703), Asian race (OR 0.756, 95% CI 0.660-0.867), and increasing recipient BMI (OR 0.982, 95% CI 0.977-0.994) after controlling for recipient age, number of embryos transferred on day 5, and unexplained infertility diagnosis. The proportion of multifetal deliveries was greater in cycles utilizing fresh (26.4%) vs. cryopreserved (20.6%) oocytes. CONCLUSION(S): The live birth rate is higher with use of fresh oocytes vs. cryopreserved oocytes in fresh embryo transfer cycles. Negative live birth predictors include recipient Black non-Hispanic or Asian race and increasing BMI.

Dual trigger protocol is an effective in vitro fertilization strategy in both normal and high responders without compromising pregnancy outcomes in fresh cycles.

OBJECTIVE: To study the birth rates of normal vs. high responders after dual trigger of final oocyte maturation with gonadotropin-releasing hormone (GnRH) agonist and human chorionic gonadotropin in fresh in vitro fertilization (IVF) cycles in which ovarian stimulation was achieved by a flexible GnRH antagonist protocol. DESIGN: Retrospective cohort study. SETTING: University hospital. PATIENTS: In women <35 years of age, 290 fresh IVF cycles using the dual trigger protocol with day 5 embryo transfers from January 2013 to July 2018 were included. Cycles excluded were those with preimplantation genetic testing, gestational carriers, donor oocytes, and fertility preservation. INTERVENTIONS: IVF with dual trigger. MAIN OUTCOME MEASURES: Clinical pregnancy rate, live birth rate. RESULTS: Comparing normal responders, defined as <30 oocytes retrieved, and high responders, defined as ≥30 oocytes retrieved, the clinical pregnancy rates (67.0% vs. 69.3%, respectively) and live birth rates (60.5% vs. 60.0%, respectively) were not significantly different. No cases of ovarian hyperstimulation syndrome were reported in either group. CONCLUSIONS: Ovarian stimulation by a flexible GnRH antagonist protocol followed by dual trigger yields comparable outcomes between normal and high responders in fresh IVF cycles.

Elective transfer of one embryo is associated with a higher cumulative live birth rate and improved perinatal outcomes compared to the transfer of two embryos with in vitro fertilization.

OBJECTIVE: To compare the effects of initial elective single embryo transfer (ieSET) and initial double embryo transfer (iDET) strategies on the cumulative live birth rate (CLBR) and perinatal outcomes after IVF. DESIGN: Retrospective cohort study. SETTING: Society for Assisted Reproductive Technology (SART) reporting clinics. PATIENTS: 49,333 patients with initial oocyte retrievals between January 2014 and December 2015. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The primary outcome was CLBR, defined as up to 1 live birth resulting from a retrieval cycle and linked transfer cycles. Secondary outcomes included cycles to pregnancy, multifetal delivery rate, infant birthweight, and perinatal mortality rate. RESULTS: Compared to iDET, ieSET was associated with increased CLBR (74% vs. 57%; adjusted odds ratio [AOR], 1.32; 95% CI, 1.26-1.38). When stratified by age, the same trend was seen in all age categories, with statistical significance for those <38 years of age. ieSET was associated with reduced multifetal delivery (8% vs. 34%; AOR, 0.13; 95% CI, 0.12-0.14), increased birthweight (mean difference, 406 grams; 95% CI, 387-425), reduced preterm births (1.2% vs. 2.8%), and reduced perinatal mortality (0.5% vs. 1.2%). Compared with iDET, ieSET was associated with slightly more embryo transfer cycles (1.7 vs. 1.4 cycles; AOR, 1.19; 95% CI, 1.16-1.21) to achieve a pregnancy resulting in live birth. CONCLUSIONS: The association of ieSET with a higher CLBR and markedly improved perinatal outcomes outweigh the relatively minor increase in time to pregnancy, reinforcing the guidance for eSET in initial transfer cycles, particularly in younger patients with a good prognosis.

The effect of weight and body mass index on serum progesterone values and live birth rate in cryopreserved in vitro fertilization cycles.

OBJECTIVE: To determine if weight or body mass index (BMI) affects the serum progesterone level at the time of the pregnancy test in cryopreserved blastocyst transfer cycles and to determine if those serum progesterone levels affect live births. DESIGN: Retrospective cohort study. SETTING: US academic medical center. PATIENTS: Six hundred thirty-three patients undergoing their first cryopreserved embryo transfer cycle. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The primary outcome was the serum progesterone level on the day of the pregnancy test by patient weight and BMI. Our secondary analysis assessed the serum progesterone effect on live birth rate (LBR) in a clinic where progesterone supplementation was increased if the progesterone level was <15 ng/mL on the day of the pregnancy test. RESULTSS: There was a strong negative correlation between serum progesterone level and both BMI and weight, with BMI accounting for 27% and weight accounting for 29% of the variance in progesterone level. Serum progesterone level on the day of the pregnancy test was <15 ng/mL in 3% of women weighing <68 kg compared with 29% of women weighing ≥90.7 kg. Among women weighing ≥90.7 kg, live birth occurred in 47% whose serum progesterone level was <15 ng/mL on the day of the pregnancy test compared with 49% in those with serum progesterone level of 15-19 ng/mL and 44% in those with serum progesterone level of ≥20 ng/mL. CONCLUSIONS: Body weight was a significant factor in serum progesterone level at the time of the pregnancy test, with nearly 30% of patients weighing ≥90.7 kg having serum progesterone level of <15 ng/mL, a value associated with lower LBRs in prior studies. However, we found no effect of low progesterone levels on LBR after cryopreserved embryo transfer cycles in a clinic where progesterone dosing was increased if serum progesterone levels were <15 ng/mL.

Condition, disease, disability: how the label used to describe infertility may affect public support for fertility treatment coverage.

PURPOSE: To assess public attitudes towards fertility treatment coverage and whether attitudes are influenced by infertility labels. METHODS: Cross-sectional, web survey-based experiment using a national sample of 1226 United States adults. Participants read identical descriptions about infertility, with the exception of random assignment to infertility being labeled as a "condition," "disease," or "disability." Participants then responded to questions measuring their beliefs and attitudes towards policies related to the diagnosis and treatment of infertility. We measured public support for infertility policies, public preference for infertility labels, and whether support differed by the randomly assigned label used. We also queried associations between demographic data and support for infertility policies. RESULTS: Support was higher for insurance coverage of infertility treatments (p=.014) and fertility preservation (p=.017), and infertility public assistance programs (p=.036) when infertility was described as a "disease" or "disability" compared to "condition." Participants who were younger, were planning or trying to conceive, had a family member or friend with infertility, and/or had a more liberal political outlook were more likely to support infertility policies. A majority of participants (78%) felt the term "condition" was the best label to describe infertility, followed by "disability" (12%). The least popular label was "disease" (10%). Those preferring "condition" were older (p<.001), more likely to be non-Hispanic White (p=.046), and less likely to have an infertility diagnosis (p<.001). CONCLUSION: While less commonly identified as the best descriptors of infertility, labeling infertility as a "disease" or "disability" may increase support for policies that improve access to infertility care.

Effect of body mass index on intrauterine insemination cycle success.

OBJECTIVE: To determine whether body mass index (BMI) affects intrauterine insemination treatment success. DESIGN: Retrospective cohort study. SETTING: Academic medical center. PATIENT(S): A total of 3,217 intrauterine insemination treatment cycles in 1,306 patients. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Primary outcome was live birth rate stratified by BMI. Secondary outcomes included rates of clinical pregnancy (defined as an intrauterine pregnancy with a heartbeat present on ultrasound), multiple gestation, biochemical pregnancy, missed abortion, ectopic, and spontaneous abortion. RESULT(S): Women with BMI 25 to 29.99 kg/m2 or ≥30 kg/m2 were equally likely to have a live birth as women of normal BMI. Women with BMI ≥30 kg/m2 did have a higher likelihood of biochemical pregnancy than women with normal BMI. CONCLUSION(S): A BMI between 25 and 29.99 kg/m2 or ≥30 kg/m2 does not appear to have a negative effect on live birth after intrauterine insemination. Obesity may be associated with a higher risk of biochemical pregnancy after intrauterine insemination.

Cellular-Enabled Glucometers and Maternal Glucose Control: A Quality Improvement Initiative.

BACKGROUND: Management of diabetes in pregnancy is burdensome due to self-glucose monitoring, recording, and reporting demands. Cellular-enabled glucometers provide real-time transmission of glucose values independent of internet access and cell phone data plans. We describe a quality improvement (QI) intervention that introduced cellular-enabled glucometers for use during pregnancies complicated by diabetes. METHODS: Our aim was to improve maternal glucose control in a cohort of insulin-requiring pregnant women enrolled in a telemedicine diabetes program. During initial establishment of a QI program, women were offered cellular-enabled glucometers but could elect to keep their standard meter. The primary outcome evaluated was glycosylated hemoglobin A1c (HbA1c) at delivery. RESULTS: Baseline characteristics including initial HbA1c were similar between women using a standard glucometer (n = 45) and those using a cellular-enabled glucometer (n = 72). Women who used a cellular-enabled glucometer had a lower HbA1c at delivery compared to those using a standard glucometer (5.8% vs 6.3%, P = .03). This improvement was particularly notable for women with poor glucose control (defined as HbA1c >6.5%) at initial obstetric visit. Women with poor glucose control who used a cellular-enabled glucose monitor had significantly lower HbA1c at delivery (6.0% vs 6.8%, P = .03) and greater change from initial visit compared to those using a standard glucometer (-2.6% vs -1.4%, P = .02). No statistically significant differences were detected in tracked neonatal outcomes. CONCLUSION: For pregnancies complicated by insulin-requiring diabetes, use of cellular-enabled glucometers as part of a perinatal diabetes program improves glucose control at delivery with timely transmission of accurate values throughout gestation.

Infertility and Health-Related Quality of Life in United States Women Veterans.

Background: To assess associations between infertility and health-related quality of life and medical comorbidities in U.S. women Veterans. Materials and Methods: This cross-sectional observational study involved computer-assisted telephone interviews of Veterans Administration-enrolled women between ages 21 and 52 years. Patients were analyzed in two groups by self-reported history of infertility. Outcomes included health-related quality of life as measured by the short-form 12-item interview (SF-12) physical and mental component summary (PCS and MCS) scores, depression, post-traumatic stress disorder (PTSD), eating disorders, fibromyalgia, other chronic pain, cardiovascular disease risk factors, and cancer. Age-adjusted p-values and adjusted odds ratios (AORs) were calculated using individual multivariate regression models to control for significant confounding covariates. Results: Of the 996 women veterans included, 179 (18.0%) reported a history of infertility. Infertility was associated with worse perceived physical health as determined by the SF-12 PCS [beta coefficient (B) -3.23 (-5.18 to -1.28)] and fibromyalgia [AOR 1.97 (1.22 to 3.19)]. Infertility was also associated with higher rates of depression, other chronic pain, and cancer, which remained significant after adjusting for age (p = 0.021, p = 0.016, and p = 0.045, respectively); however, no association for all was seen after adjustment for other significant covariates. There was no difference in Veterans' mental health using the SF-12 MCS, nor differences seen in PTSD or eating disorder rates, or in cardiovascular risk factors. Conclusions: This novel investigation in U.S. women Veterans found worse physical health-related quality of life and increased rates of fibromyalgia among women reporting a history of infertility, adding to the growing literature on infertility as a marker for overall poorer health.

A randomized controlled trial of combination letrozole and clomiphene citrate or letrozole alone for ovulation induction in women with polycystic ovary syndrome.

OBJECTIVE: To evaluate whether a combination of letrozole and clomiphene citrate (CC) results in higher ovulation rates than letrozole alone in infertile women with polycystic ovary syndrome (PCOS). DESIGN: Open-label randomized controlled trial. SETTING: Academic medical center using two clinic sites. PATIENT(S): Women 18-40 years of age with a diagnosis of infertility and PCOS as defined by the Rotterdam criteria and no other known cause of infertility. INTERVENTIONS(S): Participants were randomized in a 1:1 ratio, stratified by age and body mass index, to either 2.5 mg letrozole alone or the combination of 2.5 mg letrozole and 50 mg CC daily on cycle days 3-7 for one treatment cycle. MAIN OUTCOME MEASURE(S): Ovulation defined as mid-luteal serum progesterone concentration ≥3 ng/mL. RESULT(S): Seventy patients were randomized: 35 to letrozole alone and 35 to letrozole and CC. Results were analyzed according to the intention-to-treat principle. Women who received the combination of letrozole and CC had a statistically higher ovulation rate compared with those who received letrozole alone (27 of 35 women [77%] vs. 15 of 35 women [43%]). There were no serious adverse events or multiple-gestation pregnancies in either group. The side-effects profile was similar in the two treatment groups. CONCLUSION(S): The combination of letrozole and CC was associated with a higher ovulation rate compared with letrozole alone in women with infertility and PCOS. Further studies are needed to evaluate the effect on live birth rate. CLINICAL TRIAL REGISTRATION NUMBER: NCT02802865.

Ethnic Minority Status and Experiences of Infertility in Female Veterans.

BACKGROUND: In the general population, infertility is increasingly prevalent in ethnic minority women; these women suffer longer and are less likely to access care. There is a paucity of data regarding the issue of race and infertility in the growing female military veteran population. MATERIALS AND METHODS: This cross-sectional observational study involved computer-assisted telephone interviews of 1,004 Veterans Administration (VA)-enrolled women aged ≤52 years. RESULTS: Racial minority veterans were more likely than white veterans to self-report infertility (24% vs. 18%), equally likely to report infertility evaluation (52% vs. 52%), and less likely to report receiving infertility treatment (31% vs. 63%). Differences in self-reported infertility (odds ratios [OR]: 1.50, 95% confidence interval [CI]: 1.02-2.22) and infertility treatment (OR: 0.32, 95% CI: 0.13-0.81) were retained after controlling for age, income, marital status, education, insurance, history of pelvic inflammatory disease, and lifetime sexual assault. While racial minority veterans were equally as likely as white veterans to be evaluated for infertility, white and racial minority groups reported different reasons for not seeking evaluation. CONCLUSIONS: Consistent with civilian studies, our data suggest that racial minority VA-enrolled female veterans are more likely to self-report infertility and less likely to receive infertility treatment. Future research should investigate whether these findings are consistent nationwide and regardless of VA enrollment, and if minority veterans have unique barriers to care. A better understanding of how the VA might improve awareness of infertility evaluation and treatment options, especially for racial minority veterans, is needed.

Adherence to self-glucose monitoring recommendations and perinatal outcomes in pregnancies complicated by diabetes mellitus.

BACKGROUND: Self-glucose monitoring is critical for the management of diabetes mellitus in pregnancy; yet, validated reports of adherence to testing recommendations and associated perinatal outcomes are limited. OBJECTIVE: Using cloud-based, self-glucose monitoring technology, we sought to answer the following questions: (1) Are there differences in the rates of testing adherence based on type of diabetes mellitus in pregnancy? (2) Is adherence to glucose monitoring recommendations associated with perinatal outcomes in pregnancies that are complicated by diabetes mellitus? We hypothesized that adherence to glucose testing recommendations varies by type of diabetes mellitus and that increased adherence to testing recommendations would be associated with improved perinatal outcomes. STUDY DESIGN: This single-center, prospective cohort study included women with type 2 diabetes mellitus and gestational diabetes mellitus who were enrolled in a perinatal diabetes program at <29 weeks gestation between December 2015 and June 2018. All women received a cellular-enabled glucometer that uploaded glucose values to a cloud-based, Health Insurance Portability and Accountability Act-compliant platform in real time that ensured transmission of accurate glucose values. The primary outcome was adherence to self-glucose monitoring recommendations. Four glucose checks were advised daily, and percentage of adherence was calculated. Secondary outcomes were preeclampsia, cesarean delivery, large-for-gestational-age neonates, and neonatal hypoglycemia. The study was powered to detect a 10% difference in the primary outcome of adherence to advised self-glucose monitoring by diabetes mellitus type. Adjusted risk ratios and 95% confidence intervals were generated with the use of logistic regression. RESULTS: This study included 103 eligible women. Baseline characteristics differed between groups, with women with type 2 diabetes mellitus having higher initial HgbA1c and body mass index when compared with women with gestational diabetes mellitus. No differences were noted in age or parity. Adherence was calculated over 20±6 weeks for women with type 2 diabetes mellitus compared with 9±4 weeks for women with gestational diabetes mellitus. Overall adherence to glucose monitoring was significantly less for women with type 2 diabetes mellitus compared with those with gestational diabetes mellitus. Mean testing adherence rates were 51%, 66%, and 70% for type 2 diabetes mellitus, and gestational diabetes mellitus, class A1 and A2, respectively (P=.016). We found that, for every 10% increase in adherence to testing recommendations, the odds of cesarean delivery, neonatal hypoglycemia, and large-for-gestational-age fetuses decreases by 15-20%. There was no association between adherence and rates of preeclampsia. CONCLUSION: This study shows that overall adherence to testing recommendations differs by diabetes mellitus type and is associated with neonatal outcomes. Improved outcomes with higher adherence may reflect more timely medication adjustments in response to real-time glucose values. Programs aimed at improving adherence could prove beneficial.

Effect of body weight on early hormone levels in singleton pregnancies resulting in delivery after in vitro fertilization.

OBJECTIVE: To evaluate which clinical characteristics influence early maternal ß-human chorionic gonadotropin (hCG) and progesterone levels in in vitro fertilization (IVF) pregnancies. DESIGN: Retrospective cohort analysis. SETTING: Academic medical center. PATIENT(S): Women with a live birth after single-blastocyst embryo transfer in either a fresh or frozen cycle between 2004 and 2017, comprising 1,282 pregnancies in 1,057 patients. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The initial human chorionic gonadotropin concentration (ß-hCG1) measured a mean of 10 days (range: 9-12 days) after embryo transfer, the rate of increase in ß-hCG concentrations, and progesterone concentration, with all analyses controlled for number of days between the embryo transfer and the ß-hCG1 measurement. RESULT(S): The clinical factor that positively influenced the ß-hCG1 level in the fresh cycle was the stimulation type (antagonist cycle higher than long agonist cycle). The clinical factors that negatively influenced both fresh and frozen cycle ß-hCG1 were lower embryo quality and increasing body weight. Increasing weight negatively impacted progesterone levels in both fresh and frozen cycles. A 100 lb (45.4 kg) difference in weight was associated with a 34.8% reduction in ß-hCG1 for both fresh and frozen cycle pregnancies. The rate of increase in ß-hCG was unaffected by body weight. A 100 lb (45.4 kg) difference in weight was associated with a 53.3% and a 32.8% reduction in progesterone in fresh and frozen cycles, respectively. CONCLUSION(S): Increasing body weight is associated with significantly lower ß-hCG and progesterone concentrations in early pregnancy after blastocyst single-embryo transfer in both fresh and frozen cycles. Clinicians should consider this when evaluating these hormone levels for prognostic and diagnostic purposes.

Fertility preservation training for obstetrics and gynecology fellows: a highly desired but non-standardized experience.

BACKGROUND: Despite a large body of data suggesting that delivery of fertility care to cancer patients is inconsistent and frequently insufficient, there is a paucity of literature examining training in fertility preservation for those physicians expected to discuss options or execute therapy. The study objective was to compare fertility preservation training between Reproductive Endocrinology & Infertility (REI) and Gynecologic Oncology (GYN ONC) fellows and assess the need for additional education in this field. METHODS: A 38-item survey was administered to REI and GYN ONC fellows in the United states in April 2014. Survey items included: 1) Clinical exposure, perceived quality of training, and self-reported knowledge in fertility preservation; 2) an educational needs assessment of desire for additional training in fertility preservation. RESULTS: Seventy-nine responses were received from 137 REI and 160 GYN ONC fellows (response rate 27%). REI fellows reported seeing significantly more fertility preservation patients and rated their training more favorably than GYN ONC fellows (48% of REI fellows versus 7% of GYN ONC fellows rated training as 'excellent', p < 0.001). A majority of all fellows felt discussing fertility preservation was 'very important' but fellows differed in self-reported ability to counsel patients, with 43% of REI fellows and only 4% of GYN ONC fellows able to counsel patients 'all the time' (p = 0.002). Seventy-six percent of all fellows felt more education in fertility preservation was required, and 91% felt it should be a required component of fellowship training. CONCLUSION: Significant variability exists in fertility preservation training for REI and GYN ONC fellows, with the greatest gap seen for GYN ONC fellows, both in perceived quality of fertility preservation training and number of fertility preservation patients seen. A majority of fellows in both disciplines support the idea of a standardized multi-disciplinary curriculum in fertility preservation.

Hysterectomy risk in premenopausal-aged military veterans: associations with sexual assault and gynecologic symptoms.

BACKGROUND: Several gynecological conditions associated with hysterectomy, including abnormal bleeding and pelvic pain, have been observed at increased rates in women who have experienced sexual assault. Previous findings have suggested that one of the unique health care needs for female military veterans may be an increased prevalence of hysterectomy and that this increase may partially be due to their higher risk of sexual assault history and posttraumatic stress disorder (PTSD). Although associations between trauma, PTSD, and gynecological symptoms have been identified, little work has been done to date to directly examine the relationship between sexual assault, PTSD, and hysterectomy within the rapidly growing female veteran population. OBJECTIVES: The objective of the study was to assess the prevalence of hysterectomy in premenopausal-aged female veterans, compare with general population prevalence, and examine associations between hysterectomy and sexual assault, PTSD, and gynecological symptoms in this veteran population. STUDY DESIGN: We performed a computer-assisted telephone interview between July 2005 and August 2008 of 1004 female Veterans Affairs (VA)-enrolled veterans ≤ 52 years old from 2 Midwestern US Veterans Affairs medical centers and associated community-based outreach clinics. Within the veteran study population, associations between hysterectomy and sexual assault, PTSD, and gynecological symptoms were assessed with bivariate analyses using χ(2), Wilcoxon-Mann-Whitney, and Student t tests; multivariate logistic regression analyses were used to look for independent associations. Hysterectomy prevalence and ages were compared with large civilian populations represented in the Behavioral Risk Factor Surveillance System and American College of Surgeons National Surgical Quality Improvement Program databases from similar timeframes using χ(2) and Student t tests. RESULTS: Prevalence of hysterectomy was significantly higher (16.8% vs 13.3%, P = .0002), and mean age at hysterectomy was significantly lower (35 vs 43 years old, P < .0001) in this VA-enrolled sample of female veterans compared with civilian population-based data sets. Sixty-two percent of subjects had experienced attempted or completed sexual assault in their lifetimes. A history of completed lifetime sexual assault with vaginal penetration (LSA-V) was a significant risk factor for hysterectomy (age-adjusted odds ratio, 1.85), with those experiencing their first LSA-V in childhood or in military at particular risk. A history of PTSD was also associated with hysterectomy (age-adjusted odds ratio, 1.83), even when controlling for LSA-V. These associations were no longer significant when controlling for the increased rates of gynecological pain, abnormal gynecological bleeding, and pelvic inflammatory disease seen in those veterans with a history of LSA-V. CONCLUSION: Premenopausal-aged veterans may be at higher overall risk for hysterectomy, and for hysterectomy at younger ages, than their civilian counterparts. Veterans who have experienced completed sexual assault with vaginal penetration in childhood or in military and those with a history of PTSD may be at particularly high risk for hysterectomy, potentially related to their higher risk of gynecological symptoms. If confirmed in future studies, these findings have important implications for women's health care providers and policy makers within both the VA and civilian health care systems related to primary and secondary prevention, costs, and the potential for increased chronic disease and mortality.